Sports

Which head of the pectoralis major is often ruptured from eccentric loading injury?

Sterno-costal head typically tears (inferiorly). Often the clavicular attachment is intact.

Biomechanically what does a meniscal root tear do to a knee joint?

Results in loss of both hoop stresses and meniscal function - exposes the articular cartilage of the knee to supraphysiologic loads, decreased tibiofemoral contact area, increased peak and mean contact pressures similar to that of a total meniscectomy

In what condition can you see a posteromedial olecranon osteophyte?

Valgus extension overload / posteromedial impingement

What condition does an arm bar test diagnose?

Posteromedial impingement of the elbow

How much of the posteromedial olecranon osteophyte can be resected arthroscopically before risk of subsequent development of secondary valgus instability at the elbow?

8mm. Resection grater than or equal to 9 mm resulted in ulnar collateral ligament rupture with subsequent applied valgus stress.

When is Microfracture considered for cartilate defects?

For lesions < 2 cm squared without an underlying osseous defect

When can autologous chondrocyte implantation be used?

Lesions between 1 and 10 cm squared, but should be restricted for defects with minimal bone loss (<8mm depth).

When can osteochondral allograft be used?

For large defects with significant osseous involvement

How to do the O’Brien active compression test

Patient forward flex the shoulder to 90 adduct the shoulder 10-15 degrees, pronate the forearm, and attempt further forward flexion against resistance from the examiner. Pain in the shoulder with maneuver that is relieved when patient supinates the forearm is considered a positive test.

How do you do the lift off test and what does it signify?

Performed by having a patient stand and place the dorsum of the hand against the mid lumbar spine. Patient is then asked to lift his hand away from the back. Inability to do so indicates a tear of the subscapularis.

How to do the hornblower sign and what does it signify?

Weakness of external rotation with the patient holding his shoulder in 90 of abduction and 90 of external rotation with elbow at 90 of flexion. Examiner then performs forceful internal rotation. Weakness indicates teres minor or infraspinatus pathology.

What is the double PCL sign and what does it signify?

This sign has a high specificity for a displaced bucket handle tear of the medial meniscus

What constitutes heat exhaustion from a temperature and symptoms standpoint?

Heat exhaustion - core body temperature between 37°C (98.6°F) and 40°C (104°F). Symptoms: heavy sweating, as well as nausea; vomiting; headache; fainting; weakness; and cold or clammy skin. Fatigue, malaise, and dizziness may occur, but necessary to the diagnosis is normal mentation and stable neurologic status.

What constitutes heat stroke from temperature and symptoms standpoint?

Heat stroke - core body temperature >40°C (>104°F) and disturbances of the central nervous system, such as confusion, irritability, ataxia, and even coma.

What treatment is ideal for heat stroke?

Whole body ice bath, with ice towels, ice packs, cold water, and air fans all utilized if needed

Strongest predictor of surgery for atraumatic rotator cuff tears?

Patient expectations - physical therapy is effective treatment for atraumatic rotator cuff tears

What arm position is implicated in reverse total shoulder instability?

Extension, adduction, and internal rotation, such as pushing out of a chair

In revision shoulder arthroplasty, what outcome is most likely with using platform stems?

Shorter operative times with decreased blood loss when revising an anatomic arthroplasty to reverse arthroplasty with retention of the stem.

When is a proximal tibial osteotomy indicated in conjunction with primary or revision ACL reconstruction?

Increased tibial slope (>12°) may be a risk factor for noncontact ACL injury and subsequent failure of repair, and corrective proximal tibial osteotomy may be indicated combined with primary or revision ACL reconstruction

What are the indications for a proximal tibial valgus osteotomy?

Isolated medial compartment degeneration in a knee with varus malalignment in a young, active individual.

What distinguishes a stinger from something more serious?

Stingers present with unilateral symptoms. Bilateral symptoms can indicate a cervical neck injury.

What is the advantage of a double-row repair of a rotator cuff tear versus a single-row repair?

Superior capacity for tendon healing

What physical exam maneuver will reproduce the symptoms for posterior labral tear and posterior instability?

Flexion, adduction, and internal rotation

What shoulder pathology can predispose athletes to medial elbow injuries?

Decreases in total arc of motion, commonly associated with glenohumeral internal rotation deficits (GIRD)

Following mechanical injury to cartilage, chondrocytes degrade by what mechanism?

Apoptosis

Can an athlete go back to play if diagnosed with concussion?

Not on the day of injury

What is Relative Energy Deficiency in Sports?

Low energy availability, menstrual dysfunction, altered bone mineral density

What are the two bundles of the ACL?

Anteromedial bundle - tight in flexion

Posterolateral bundle - tight in extension

What is the main blood supply to the ACL and PCL?

Middle geniculate artery

Where is the footprint of the ACL in relation to the PCL

10-11mm anterior to the PCL

What can occur with femoral tunnel malposition in terms of the ACL?

Too anterior tunnel - ACL tight in flexion and lax in extension

Too posterior tunnel - ACL will be tight in extension

What are the two bundles of the PCL?

Anterolateral - tight in flexion

Posteromedial - tight in extension

What is a minscus composed of?

Extracellular matrix produced by fibrochondrocytes

• Primarily type I collagen, small amounts of type II, III, V, VI

• Water, proteglycans

When is the medial meniscus a dynamic stabilizer?

Secondary stabilizer during anterior tibial translation

When is the lateral meniscus a dynamic stabilizer?

Stabilizer for rotation and valgus loads during pivot shift maneuver in ACL deficient knee

What is a meniscus root tear?

Radial tear or avulsion of the meniscal root from the tibial plateau - complete disruption of the circumferential fibers. Causes loss of hoop stresses and increase in contact forces

What type of sutures for meniscus repair are the strongest?

Vertical mattress sutures

What is the gold standard for meniscus repair techniques?

Inside-out

What are the indications for meniscal transplant?

• Prior total or near-total meniscectomy

• Pain in involved compartment

• BMI < 30

• Normal alignment

• Ligamentous stability

Contraindications for meniscal transplant?

• Diffuse grades III and IV chondral changes

• Kissing lesions

• Advanced patient age

• Inflammatory arthritis

• Synovial disease

• Uncorrected mechanical axis that lies in affected compartment

What can be seen on xrays that imply a discoid meniscus?

Widened joint space, squaring of the lateral femoral condyle, cupping of the lateral tibial plateau, hypoplastic lateral intercondylar spine

What type of collagen makes up articular cartilage?

Type II hyaline cartilage

Fibrocartilaginous scar is made up of what type of cartilage?

Type I

What type of chondral defects can osteochondral autograft transplant be used?

Small < 2cm chondral or osteochondral defects

When is an osteochondral allograft transplant used?

Large (>2-4cm) chondral or osteochondral defects

How quickly should the osteochondral allograft be transplanted?

Within 28 days of harvest

What is an autologous chondrocyte implantation?

Articular cartilage-restoring procedure for medium to large (>2-4cm) full thickness chondral defects (no bone involvement)

What are indications for a valgus producing osteotomy of the knee?

• Physiological age < 60 in an athlete, laborer, active patient

• < 15 degrees fixed varus deformity

• < 15 degrees flexion contracture

• Mild-moderate medial compartment degenerative joint disease

What is the ober test and how is it done?

Patient is on the side with the symptomatic leg up, the hip is taken from flexion/adduction to extension/abduction and it tests for IT band syndrome

What alpha angle measured on the 45 degree Dunn view is diagnostic of a cam lesion?

Alpha angle > 50 or 55 degrees

What is the crossover sign?

On AP pelvis xray, it suggests acetabular retroversion or pincer lesion

What is the normal lateral center edge angle measured on AP xray?

Normal LCEA between 25-40 degrees

>40 degrees - coxa profunda

< 18-25 degrees - hip dysplasia

What are the contraindications for hip arthroscopy?

Osteoarthritis, hip dysplasia

What nerve is at risk during hip arthroscopy with post?

Pudendal nerve palsy

How much of the femoral head diameter can be taken away during hip scope before worrying about femoral neck fracture?

If >30% of diameter is taken away, risk for femoral neck fracture

What is the risk with the anterolateral hip scope portal?

If too proximal, superior gluteal nerve at risk

What is a risk factor with the posterolateral hip scope portal?

Sciatic nerve at risk

What structures are at risk with the modified mid-anterior portal if made too medial?

Femoral artery and nerve, lateral femoral cutaneous nerve

What two ligaments are commonly injured with ankle sprain?

ATLF, CFL

What maneuver will test the ATFL ligament?

Anterior drawer test - ankle slightly plantarflexed, positive if >3-5mm more translation than other side

What maneuver will test the CFL ligament?

Talar tilt test - ankle in neutral with inversion stress - positive if increased laxity compared to contralateral side

What is the most common complication of operative treatment of achilles rupture?

Wound healing

What nerve is at risk with percutaneous repair of an Achilles tendon rupture?

Sural nerve injury

What is turf toe?

1st MTP hyperextension injury due to incompetent plantar plate and sesamoid complex

What is the Brostrom procedure?

Midsubstance suturing and shortening of torn ends of ATFL/CFL, with lateral extensor retinaculum advanced to fibula over the ligament repair

What are the borders of the rotator interval?

Medial - coracoid

Superior - Supraspinatus

Inferior - Subscapularis

What are the contents of the rotator interval?

Biceps, SGHL, Coracohumeral ligament, capsule

What ligament is associated with bankart lesions?

Anterior IGHL

What position of the arm puts the most tension on the anterior IGHL?

Max ER and abduction at 90 degrees

What position puts max tension on the anterior MGHL?

Max ER and abduction at 45 degrees

What is a bankart lesion?

avulsion of the IGHL from anterior inferior glenoid

What is a HAGL lesion?

Avulsion of the GH ligament off the humerus

What amount of bone loss of the glenoid is critical?

20-25%

What are the surgical indications for anterior shoulder instability?

Fractures, contact young athletes, failure of conservative treatment, 2+ dislocations

What are the indications for an arthroscopic bankart repair?

First time dislocator in an athlete < 25 years old

recurrent dislocator

< 10-20% bone loss

What is the reimplissage procedure?

Tie in some of the infraspinatus muscle into the defect of the hill sachs

What are the indications for the latarjet procedure?

>20% bone loss, recurrent dislocator

What are complications of the latarjet procedure?

MCN, axillary nerve palsy

Graft malposition

Nonunion

Biggest risk factor for recurrent instability of the shoulder?

< 25 years old

What is a GLAD lesion?

Labrum + cartilage

What is an ALPSA lesion?

Periosteal labral sleeve avulsion

What is a Bennett lesion?

Posterior inferior labrum mineralization

What is the most common nerve injury with a Latarjet procedure?

Musculocutaneous, then axillary

What structure is affected with posterior shoulder instability?

Posterior IGHL

What physical exam tests are used to diagnose posterior shoulder instability?

Flexion, adduction, IR

Load and shift test

jerk test

kim test

What are risk factors for recurrent instability for posterior shoulder instability?

Young age, bony lesion, seizures

What are surgical indications for posterior instability?

Failure of conservative treatments

recurrent instability

Locked dislocation

Main complication for surgical treatment of posterior instability?

Recurrence or stiffness

What is a Kim lesion?

tear between the posterior inferior labrum and glenoid

What is the surgical treatment for multidirectional instability?

Capsular shift (270 degrees), rotator interval closure

What is a buford complex?

Sublabral foramen and cordlike MGHL

What phase do throwing athletes get a SLAP tear?

Late cocking phase

What are the surgical indications for a treatment of biceps/SLAP?

Medial subluxation

Failed nonop

What are the exam maneuvers for the supraspinatus muscle?

Empty can test, codman test, drop arm test

What are the physical exam maneuvers for infraspinatus muscle?

Empty can, drop arm test

What muscle does the hornblower test?

Teres minor

What are the surgical indications for acute rotator cuff tear?

Traumatic injury, immediate loss of function, no muscle atrophy

What is the rotator cable?

“Suspension bridge” - made up of supra-infra-subscap

What coracoclavicular ligament is the strongest?

Conoid - located 4.5 cm from the AC joint

What xray view is specific for the AC joint and how is it obtained?

Zanca view - beam 10 degrees cephalad with 50% penetration